Client Information Form | Genova Diagnostics

Practitioner Details

First Name*

Last Name*

Degree(s)*

NPI Number

Applicable to US practitioners only

PECOS Status*

More about PECOS

Office or Clinic Name

Phone Number*

Fax Number

Email Address*

Why we ask for your email address

How did you learn about Genova Diagnostics?*

Which Conference or Seminar did you attend?*

Terms and Conditions*

I agree to Genova Diagnostics' Terms & Conditions and Privacy Policy

License

To ensure the quickest possible turnaround time in setting up your account, we ask that you provide an electronic copy (PDF) of the Ordering Healthcare Practitioner's license that shows the expiration date or a copy of a voided prescription pad form.

Practitioners licensed outside of the US should check with their country's health ministry or regulatory body regarding appropriate documentation.

Shipping Address

Collection packs and results will be sent to this address

Country*

Street Address or PO Box*

Apt/Suite/Other

City

State/Province

Postal/Zip Code

Billing Information

Billing Contact Information

Please take a moment to review the following options and let us know which one applies to your account:

Setting Up a New Billing Account

Joining an Existing Billing Account

Name / Title*

Email Address*

Billing Office*

Billing Account Number

Billing Statement Preference

Please enroll me in paperless billing.

If you are wanting to combine your account with another practitioner/entity for reasons other than billing, please submit your application and then proceed to get in touch with your new account rep by completing this form: https://www.gdx.net/contact/more-information

Billing Method Preferences

These preferences may need to be adjusted by our account set-up specialist team based on regulatory requirements for your state.

Allow the following billing methods

Bill Practitioner Account (not available in NY, NJ or RI)

Patient Prepay

Insurance

Medicare (valid NPI and PECOS enrollment required)

Genova Diagnostics will quote payment amounts to patients who are using our insurance billing and no insurance billing options. If you would like for us to alter this account setting, please reach out to us at 800-522-4762 after your account has been created.

Convenient and Secure Automated Payment Options for Practitioner Billing

At the beginning of each month, Genova Diagnositcs will provide a comprehensive list of charges made to your card. Automated payments will be charged at the end of each month for any balances remaining on the account.

Please provide your card details and specify your preference for storing and using it for balances billed to your professional account.

Payment Information

I authorize Genova Diagnostics to charge my card:

Upon completion of any laboratory testing indicated to be billed to my account.

The remaining balance on my account at the end of each month.

Only for past due balances on my account. Balances are past due if they remain unpaid 30 days after they appear on a billing statement.

Name on Card*

Card Number*

Expiration*

Client Application

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General Information